Forum - Questions & Answers

Jan 15th, 2015 - cmgmr 4 

Chart Documentation

I work for a Hospital based Primary Care Center. There are multiple providers which includes 3 Physicians, 3 Nurse Practitioner's and 2 Physician Assistants. They all complete their chart documentation differently. My question is this; is a chart note considered completed if it is missing either the HPI or the ROS? I understand it is the responsibility of the Provider to complete the HPI documentation. What about the ROS? If none is documented is the office note considered complete?

Jan 15th, 2015 - jvosfernea 66 

re: Chart Documentation

"Complete" depends on what CPT® code is being billed and whether the note is being billed 'by time' or 'by complexity'. If "50% or more of this session was focused on counseling for _______________, for which results ..__________", then the issue of ROS/HPI, etc, changes.

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